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MRCOG Part 2 > Gynaecological problems > Flashcards

Gynaecological problems Flashcards

1
Q

How should the increased risk of endometrial hyperplasia in PCOS be managed?

A

Progestogens should be used to induce a withdrawal bleed at least every 3-4 months

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1
Q

How should women with PCOS be screened for T2DM?

A

If they have both PCOS and are overweight or have PCOS plus additional risk factors, they should be offered an OGTT

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2
Q

What is the link between PCOS and both breast and ovarian cancers?

A

There does not appear to be an association between PCOS and breast and ovarian cancer

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3
Q

What are the Rotterdam criteria for diagnosis of PCOS?

A
  1. polycystic ovaries with either 12 or more follicles, or ovarian volume >10cm
  2. Oligo-ovulation or anovulation
  3. Clinical and/or biochemical signs of hyperandrogenism
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4
Q

How can CAH be investigated for in rapidly progressing hirsuitism?

A

17-Hydroxyprogesterone is measured in the follicular phase and will be raised in CAH

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5
Q

If 17-hydroxyprogesterone is borderline, which test is used to confirm diagnosis of CAH?

A

ACTH stimulation test

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6
Q

What is the incidence of symptomatic ovarian cysts in premenopausal women being malignant?

A

1:1,000

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7
Q

What percentage of suspected ovarian masses are ultimately found to be non-ovarian in origin?

A

10%

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8
Q

What is the management of a simple ovarian cyst <50mm in a pre-menopausal woman?

A

Conservative: the majority will resolve over 2-3 menstrual cycles without intervention

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9
Q

What is the role of LDH, afp and hCG measurement in evaluation of cysts in pre-menopausal women?

A

Should be undertaken for all women under 40 with complex ovarian mass due to the risk of germ cell tumours

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10
Q

CA125 is primarily a marker for which ovarian cancer?

A

Epithelial ovarian carcinoma

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11
Q

Which scoring system does GTG advocate for assessing risk of malignancy and how is it calculated?

A

RMI 1:
RMI = U x M x CA125

1 point for premenopausal, 3 points for postmenopausal
1 point for ultrasound score 1, 3 points for ultrasound score 2-5

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12
Q

What are the sensitivity and specificity of using RMI 200 as a cut off for malignancy?

A

Sensitivity 78%
Specificity 87%

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13
Q

What are the sensitivity and specificity of using IOTA rules for classifying masses as benign or malignant?

A

Sensitivity 95%
Specificity 91%

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14
Q

What are the M-rules for IOTA classification?

A

Irregular solid tumour
Ascites
At least 4 papillary structures
Irregular multilocular solid tumour with largest diameter >=100mm
very strong blood flow

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15
Q

How should premenopausal women with simple cysts of 50-70mm be managed?

A

With yearly followup ultrasound

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16
Q

How should premenopausal women with simple cysts >70mm be managed?

A

Either MRI or surgical management

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17
Q

How should women with a cyst growing between interval scans be managed?

A

RMI score followed by operative management

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18
Q

What is the effect of COCP on functional ovarian cysts?

A

COCP does not promote the resolution of functional ovarian cysts

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19
Q

What is the range of recurrence rate for ovarian cysts following needle aspiration?

A

Between 53-84%

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20
Q

What are the first and second line investigations for pre-menstrual syndrome?

A
  1. Symptom diary
  2. GnRH analogues for 3 months
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21
Q

What 3 treatments should be trialed in primary care prior to secondary referral for pre-menstrual syndrome?

A
  1. COCP
  2. Vitamin B6
  3. SSRI
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22
Q

Which COCPs should be considered first line for pre-menstrual syndrome?

A

Drospirenone-containing COCP

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23
Q

Should COCP be taken continuously or cyclically for women with PMS?

A

Continuously

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24
Q

Which medications need to be used with caution for women with PMS?

A

Progestogens (though micronised progestogens may be better)

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25
Q

Which medication given for PMS requires barrier contraception and why?

A

Danazol; it may cause virilisation of a female fetus

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26
Q

Which monitoring test is required for women on long term GnRH analogues for PMS and how often?

A

DEXA should be performed yearly

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27
Q

What advice should women on SSRIs for PMS be given when they fall pregnant?

A

They should stop SSRIs in pregnancy as their PMS symptoms will cease

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28
Q

Why is bilateral oophorectomy without hysterectomy not recommended for management of PMS?

A

This would necessitate progesterone replacement for endometrial protection and would risk stimulating PMS

29
Q

What percentage of women experience symptoms of PMS?

A

40%

30
Q

Of women who experience PMS, what percentage (range) suffer from severe PMS?

A

5-8%

31
Q

What is the most reliable questionnaire used for a PMS symptoms diary called?

A

The Daily Record of Severity of Problems

32
Q

What is the daily dose of Vitamin B6 restricted to and why?

A

10mg due to risk of peripheral neuropathy at higher doses

33
Q

What should women be warned of when using the Levonorgestrel-releasing IUS for the progestogenic component of PMS treatment?

A

The low levels of progesterone in the coil may initially cause some PMS symptoms

34
Q

Which diuretic can be used for PMS symptoms?

A

Spironolactone

35
Q

What is the lifetime prevalence of fibroids?

A

30%

36
Q

Aside from ethnicity, what are the risk factors for development of fibroids?

A

Obesity
Nulliparity

37
Q

What proportion of women with fibroids are symptomatic?

A

25%

38
Q

By what percentage did fibroids shrink after 12 weeks of GnRH treatment in the Cochrane review?

A

36%

39
Q

Why is Ullipristal Acetate no longer used for uterine fibroids?

A

Long term usage carriers a risk of liver failure

40
Q

What is the Odds Ratio for reintervention after uterine artery embolisation compared to myomectomy?

A

10.45

41
Q

How should a unilocular, simple ovarian cyst of less than 5cm diameter be managed in a postmenopausal woman, when the CA125 is low?

A

Surveillance ultrasound at 4-6 months
Can discharge after 1 year if no interval growth

42
Q

What operation should be performed for a symptomatic postmenopausal woman with a simple, low risk cyst?

A

Laparoscopic bilateral salpingo-oophorectomy

43
Q

What operation should be performed for a postmenopausal woman with RMI I >200?

A

Staging laparotomy

44
Q

CA125 is raised in over 80% of which ovarian cancers?

A

Epithelial ovarian cancer

45
Q

CA125 is not usually raised in which type of ovarian cancer?

A

Primary mucinous ovarian cancer

46
Q

CA125 alone has a pooled sensitivity and specificity of what for differentiating benign from malignant masses?

A

78%

47
Q

What are the 5 features of simple cysts on TVUSS?

A
  1. Round or oval shape
  2. Thin or imperceptible wall
  3. Posterior acoustic enhancement
  4. Anechoic fluid
  5. Absence of septations or nodules
48
Q

What are the 3 ultrasound features of complex ovarian cysts?

A
  1. Complete septation
  2. Solid nodules
  3. Papillary projections
49
Q

What percentage of simple cysts <5cm in postmenopausal women will disappear by 24 months?

A

53%

50
Q

What features on ultrasound contribute to the “ultrasound score” portion of RMI?

A

Multilocular
Solid areas
Metastases
Ascites
Bilateral lesions

51
Q

What is the sensitivity and specificity of RMI when a cutoff off 250 is used?

A

70% sensitivity and 90% specificity

52
Q

What should be included in staging laparotomy?

A

Laparotomy
Cytology from either ascites or washings
TAH, BSO and omentectomy
Biopsies from any suspicious areas

53
Q

What 5 criteria can be used to stratify risk of ovarian torsion?

A
  1. Unilateral lumbar or abdominal pain
  2. Pain duration <8 hours
  3. Vomiting
  4. Absence or leucorrhea/metorrhagia
  5. Ovarian cyst >5cm
54
Q

Ovarian cysts are seen in what percentage of pregnancies?

A

up to 5%

55
Q

How should cystectomy be performed in the context of torsion?

A

Interval cystectomy 2-3 weeks after detorsion

56
Q

What proportion of TOAs occur in nulliparous women?

A

60%

57
Q

What is the mortality rate of TOA when associated with severe systemic sepsis?

A

5-10%

58
Q

What proportion of women being treated for proven PID will be diagnosed with a TOA?

A

15-35%

59
Q

Which two symptoms/signs are more common in women with TOA than PID?

A

Fever
Diarrhoea

60
Q

What is the most sensitive predictor of a TOA?

A

High CRP along with clinical signs

61
Q

What is a cogwheel sign thought to be pathognomonic of?

A

Acute tubal inflammation
(as seen in TOA)

62
Q

Which CT finding is usually associated with bowel-associated abscesses and is uncommon in TOA?

A

Internal gas bubbles

63
Q

What structure, if seen entering an adnexal mass on CT, allows for differentiation between TOA and periappendicular abscess?

A

The ovarian vein

64
Q

Which antibiotics have higher abscess cavity penetration and have been shown to reduce abscess size?

A

Clindamycin
Metronidazole
Cefoxitin

65
Q

Which factors are associated with poor prognosis for recovery after TOA?

A

Abscess >5cm
Age >40
Smoking
Higher initial WCC

66
Q

What is the likelihood of postmenopausal women with TOA having an associated malignancy?

A

47%

67
Q

Why rare complications of TOA should be imaged for in women who do not improve following surgery with sustained pyrexia?

A

Subphrenic abscess
Intrathoracic abscess

68
Q

What percentage of women with TOA who undergo percutaneous drainage are able to avoid surgery?

A

81%

69
Q

Risk of pregnancy when removing an IUS/IUD from a woman with TOA should be considered if the women has had unprotected intercourse within how many days?

A

5

70
Q

Which antibiotics does Actinomyces commonly respond to?

A

Penicillin

71
Q
A

MRCOG Part 2 (11 decks)

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